Project Summary/Abstract Kidney transplantation (KT) is the optimal treatment for end-stage kidney disease (ESKD). It reduces mortality, improves quality of life, and costs less than dialysis. Previous research demonstrated significant disparities in ESKD and its treatment for members of disadvantaged groups [e.g., Hispanic/Latino (HL), American Indians (AI), low income]. Although HL and AI are referred for KT equally with non-Hispanic whites (WH), they are less likely to be wait-listed or to undergo KT than WH. These findings speak to the importance of research focusing on disparities in the evaluation process occurring after referral for KT, rather than on the referral itself. The KT evaluation process is lengthy, time consuming, and burdensome, requiring patients to complete numerous tests to be presented to the transplant team and accepted for KT. Patients must complete testing on their own, which requires them to take charge of a complex series of tests and follow-up visits with specialist providers. Most efforts to reduce disparities in KT emphasize educating or changing the behavior of patients on dialysis who have not been referred for KT. But these approaches do not reduce the burden of the evaluation process on the patient. Further, educating patients does not eliminate external barriers that may prevent patients from completing KT evaluation despite their best intentions to do so. Instead, altering the way care is delivered to patients, by changing the demands of the KT evaluation process on the patient, will significantly reduce KT disparities. The proposed study will assess whether Kidney Transplant Fast Track (KTFT), a streamlined KT evaluation process, or peer navigators (PN) who were former KT patients to help patients ?navigate? their way through KT evaluation, can help vulnerable patients with ESKD overcome barriers to transplant listing. After culturally and contextually adapting the two interventions, we will use a comparative effectiveness (CER) approach to conduct a pragmatic randomized trial of 398 ESKD patients to compare the efficacy and effectiveness of the two approaches in disadvantaged groups at a university-affiliated transplant center with large HL and AI ESKD patient populations, and we will compare results to historic comparison populations (local and national). We will assess facilitators and barriers to widespread implementation and conduct a cost effectiveness analysis. Although it is expected that KTFT will be more effective than PN, KTFT may also be more costly, requiring significant administrative and clinical changes in the transplant center, which may be impractical to maintain. Further, KTFT may lead to more patient ambivalence because the shortened evaluation period will give them less time to consider their treatment options. Thus, an important aspect of the proposed study is to comparative the effectiveness of the two methods. Ultimately, our study will inform transplant programs faced with disparities in KT about which disparity-reducing intervention to use given their particular needs and resources.